Basic Information
| Provider Information | |||||||||
| NPI: | 1619580057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONICO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3952D CLAIREMONT MESA BLVD # 452 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921172714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046089379 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 591 CAMINO DE LA REINA STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921083104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192065271 | ||||||||
| FaxNumber: | 6197953274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C009649 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW96008 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.